The nutritional care of children and young people with chronic kidney disease

Abstract

Chronic kidney disease (CKD) has a complex relationship with nutritional status. Children and young people
with CKD have poorer nutritional status than their healthy counterparts. This may have an irreversible, negative,
lifelong impact (1). This thesis explores how current clinical practice can characterise the clinical and nutritional
status of children and young people with CKD, and proposes a relationship between disease severity, nutritional
status, clinical outcomes, and disease activity.
A cross-sectional study reporting the growth data of children and young people attending a paediatric
nephrology service found that short stature (height standard deviation score (SDS) <-2) and obesity (body-mass
index SDS >2) were prevalent (10% and 12%, respectively), and variation not explained by disease severity
alone.
A novel systematic framework approach to examining the literature was developed and when applied
demonstrated the limitations of the published evidence on vitamin and mineral requirements in CKD to inform
clinical decision making and management. What evidence that does exist is at high risk of bias. Application of
this framework may be used to develop a more structured approach to management of micronutrients in CKD.
A cross-sectional study nutritionally characterising a cohort of 60 children and young people with CKD
revealed variation of anthropometry, dietary intake, and blood concentrations of nutrients. Dietary intake
assessment using current practice suggested that many children are at risk of nutritional inadequacy but was not
supported by biochemical measures, which for the majority lay within the normal reference range. The
exceptions were elevated concentrations of vitamins A and E.
Appetite was explored in this cohort through the development of a novel structured patient questionnaire that
offers a broader and more complete characterisation of appetite. Using this approach revealed that self-reported
appetite was poor in 25% of the cohort.
Poorer health-related quality of life (HRQoL), as assessed by a validated questionnaire (PedsQL) was reported
in the cohort and was associated with poor nutritional status as marked by height SDS, and appetite. This
association strengthens the importance of nutritional status as an important metric for patients.
A time-limited trial of a novel vitamin and mineral food for special medicinal purposes was poorly tolerated,
but in those children who adhered to the intervention was associated with changes in blood concentrations of
micronutrients, including selenium.
Finally, two putative markers of disease activity were explored. The distribution of red cell distribution width
within the cohort was similar to that of a healthy population, and did not show any association with disease
severity. RDW was negatively correlated with weight and mid-upper arm circumference, which may suggest a
relationship between acute nutritional status and/or muscle mass. Urinary neutrophil gelatinase-associated
lipocalin (uNGAL) was demonstrated to be elevated, and a predictor of kidney disease progression at 12 months
compared to protein-to-creatinine ratio. An association with uNGAL and plasma selenium and vitamin B12
concentrations was observed that may mark a possible underlying mechanistic understanding of micronutrientkidney
disease interactions.
Herein, it is demonstrated that there is variability in nutritional status, appetite, health-related quality of life, and
proposed markers of disease activity that are not entirely explained through variation in disease severity. As
current approaches routinely applied in clinical practice may not adequately describe the nutritional state of
children with CKD, there may be value in introducing a more structured approach to nutritional management of
CKD.

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